Home health agencies (HHA) are an increasingly important provider of postacute care (PAC) to older[unreadable] Americans. The number of HHA increased 17% in the last five years and personal home health care[unreadable] expenditures increased from $12.6 billion to $40 billion from 1990 to 2003 Medicare finances care for almost 3[unreadable] million HHA patients annually and almost half of these are admitted into HHAs following an acute care[unreadable] hospitalization. Research has found clinical benefits for PAC HHA patients as compared to other PAC settings,[unreadable] but the annual rate of hospital readmissions for PAC Medicare home health beneficiaries is persistently high, at[unreadable] almost 50%. Rehospitalization increases healthcare system costs, and particularly for older adults, increases[unreadable] risks for adverse physical and cognitive health outcomes. High readmission rates among PAC HHA patients[unreadable] and the relative absence of studies of HHA organizational and market impacts on HHA quality call out for[unreadable] research to identify factors influencing these rates. In 2000, 49% of all Medicare certified agencies were[unreadable] proprietary and, over two decades, striking changes in the structure and relationships among healthcare[unreadable] providers, such as increased integration, and dramatically expanded demand for PAC services, have had[unreadable] implications for the competitiveness of the PAC and HHA market. The specific aims for the dissertation work to[unreadable] be supported by this grant are: 1) To quantify the impact of profit orientation on risk of poor quality PAC for[unreadable] HHA patients, measured as rehospitalization risk; 2) To assess the impact of market-level PAC competition on[unreadable] quality of HHA care; and 3) To assess the impact of market competition on the relationship between HHA profit[unreadable] orientation and quality. Conceptually, this study asks whether a clash of organizational goals, occurring when[unreadable] patient care comes at the cost of profits, results in poorer care from for-profit HHA. Also, differential availability[unreadable] of market resources may affect how HHAs care for patients, as choices for resource reallocation to better[unreadable] compete with other PAC providers may be detrimental to quality patient care. Do agencies act more alike,[unreadable] regardless of profit orientation, under high levels of competition, or do agencies respond differently by profit[unreadable] orientation? This research fills a gap in the literature by using recent data from a longitudinal census of every[unreadable] patient in Medicare certified HHA (the Outcome Assessment Information Set) linked with publicly available[unreadable] agency- and market-level data. This large dataset allows for control of individual-, agency- and market- level[unreadable] influences on rehospitalization. Multilevel modeling will account for clustering of patients within agencies and[unreadable] agencies within markets and a polytomous outcome will account for competing risks for other discharge[unreadable] outcomes. Market competition from other types of PAC providers will be considered in addition to competition[unreadable] from other HHA. Study results will add to the important ongoing debate about the public value of not-for-profits[unreadable] and potentially inform legislators considering policy impacting healthcare competition.